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13 Ethinyl oestradiol in the aquatic
environment
Susan Jobling and Richard Owen
Many decades of research have shown that when released to the environment, a group of
hormones known as oestrogens, both synthetic and naturally occurring, can have serious
impacts on wildlife. This includes the development of intersex characteristics in male fish, which
diminishes fertility and fecundity. Although often sublethal, such impacts may be permanent and
irreversible.
This chapter describes the scientific evidence and regulatory debates concerning one of these
oestrogens, ethinyloestradiol (EE2), an active ingredient in the birth control pill. First developed
in 1938, it is released to the aquatic environment via wastewater treatment plants. Although it is
now clear that wildlife species are exposed to and impacted by a cocktail of endocrine disrupting
chemicals, there is also reasonable scientific certainty that EE2 plays a significant role, and at
vanishingly low levels in the environment.
In 2004 the Environment Agency of England and Wales accepted this, judging the evidence
sufficient to warrant consideration of risk management. In 2012, nearly 75 years after its
synthesis, the European Commission proposed to regulate EE2 as a EU-wide 'priority substance'
under the Water Framework Directive (the primary legislation for protecting and conserving
European water bodies). This proposal was subsequently amended, delaying any decision on a
regulatory 'environmental quality standard' until at least 2016.
This is in part because control of EE2 will come at a significant price. Complying with proposed
regulatory limits in the environment means removing very low (part per trillion) levels of EE2
from wastewater effluents at considerable expense.
Is this a price we are willing to pay? Or will the price of precautionary action be simply too
high — a pill too bitter to swallow? To what extent is society, which has enjoyed decades of
flexible fertility and will also ultimately pay for the control and management of its unintended
consequences, involved in this decision? And what could this mean for the many thousands
of other pharmaceuticals that ubiquitously infiltrate our environment and which could have
sublethal effects on aquatic animals at similarly low levels?
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Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
13.1 Introduction
A large body of scientific data built up over many
decades indicates a cause-effect link between
exposure to a complex cocktail of chemicals and
the feminisation and demasculinisation of wildlife
species, particularly those living in or around the
aquatic environment (reviewed in Lyons, 2008).
Some scientists also relate exposure to hormonally
active chemicals (so-called 'endocrine disruptors',
including alkylphenols, bisphenol-A, phthalates,
flame retardants and many other chemicals in
everyday use) to declining sperm counts, increased
incidence of male genital abnormalities, testicular,
breast and prostate cancer in human populations
(Lyons, 2008; Sharpe, 2009), breast growth in young
men (Henley et al., 2007), and early onset of puberty
in young girls (Den Hond and Schoeters, 2006;
Jacobson-Dickman and Lee, 2009).
Over the last 50 years, since the publication of
Silent Spring by Rachel Carson in 1962, we have
learned that chemicals in food, household products,
medicines and cosmetics, can be and are harmful to
wildlife at very low levels. Many of these chemicals,
each present at vanishingly low (parts per trillion)
concentrations, can together have additive biological
effects — producing 'something from nothing' in
the words of Silva et al. (2002). Awareness of this
reality has awoken scientists and the public to an era
of possible harms from low-level, chronic chemical
pollution (e.g. from human pharmaceuticals).
These chemicals may not have obvious catastrophic
effects such as those observed for the endocrine
disrupting anti-foulant tributyltin (TBT), which
devastated commercially important oyster
populations (see EEA, 2001, Ch. 13 on TBT and Gee,
2006). They can, however, have less obvious effects
that nonetheless cause irreversible harm to individual
organisms. This raises difficult questions concerning
the relationship between these damaging but
sub‑lethal impacts on wildlife and their connections
to ecological (e.g. population level) impacts,
and to human health. It also raises issues for the
precautionary principle, which states that where there
is evidence of damage and irreversible harm, lack
of full scientific certainty should not excuse inaction
(UN, 1992). As we shall describe, the evidence
suggests that it is entirely reasonable to invoke the
precautionary principle and introduce regulation to
limit aquatic exposure to EE2. But this is no trivial
matter, and the reasons for this raise serious questions
for the precautionary principle itself.
This is the story of one of these chemical pollutants,
the contraceptive pill hormone 17α-ethinyloestradiol
(EE2) as it has unfolded in the United Kingdom
from the 1970s to today
13.1.1 The contraceptive pill
The first orally active synthetic steroidal oestrogen,
EE2 (1), was synthesised by Hans Herloff Inhoffen
and Walter Hohlweg at Schering AG in Berlin
(Inhoffen and Hohlweg, 1938; Maisel, 1965) in 1938.
EE2 was invented at a time when scientists across
the world were intensifying their research into sex
hormones as a means of controlling fertility and
gynecological disorders. They were inspired by the
remarkable successes achieved during the 1920s in
using insulin to treat diabetes, thyroxine to alleviate
thyroid deficiencies and metabolic disorders, and
by the discovery of progesterone, the ovulation
preventing hormone in 1934 (Sneader, 1985).
At a similar time, Edward Charles Dodds, a
British medical researcher, discovered the potent
oestrogenic properties of diethylstilbesterol
(Dodds et al., 1938; EEA, 2001, Ch. 8) and those
of bisphenol-A and 4-nonylphenol (Dodds et al.,
1936), now well known endocrine disrupting
chemicals. While BPA (see Chapter 10 on BPA)
and 4-nonylphenol never found uses as drugs
(their future was to be in plastics and detergents,
respectively), for many medical practitioners and
scientists there seemed no limit to the extent to
which artificial oestrogens could be put to good
medical use. EE2 was first marketed by Schering
as Estinyl in 1943 and initially used to manage
menopausal symptoms and female hypogonadism.
It appeared to be readily absorbed orally and very
resistant to degradation and metabolism by the gut.
The stability and effects of EE2 paved the way for
developing oral contraceptive pills ('the pill'), which
eventually occurred in the 1950s and 1960s (Medical
News, 1961).
The development of the pill was powerfully
intertwined both with concerns about
overpopulation and the 'sexual revolution' of the
1960s. Symbolically, it was much more than a tool
for contraception. From the start it was linked with
the hopes that it could curb population growth
and bring about world stability. The first version
of the contraceptive pill (Enovid) contained the
hormones mestranol (the methyl ether of ethinyl
oestradiol) and norethynodrel (a progesterone-like
(1) 17α-ethinyloestradiol is the 17α-ethinyl analogue of the natural female hormone, 17β-oestradiol.
280
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Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
hormone). As Dr John Rock, a catholic obstetriciangynecologist who ran some of the first clinical trials
of the birth control pill, noted in 1967, 'If taken as
it should be … it will stop ovulation 100 per cent'
(CBC digital Archives, 1964).
2006) — compared to only 3 % of women in Japan
(Hayashi, 2004; Hayes, 2009), which, in 1999,
became the last country in the developed world to
legalise the pill.
Today the mechanisms of action of synthetic
oestrogens and progestogens (2) are well
understood. They are taken up by the cells in
the reproductive system, pituitary, bone, liver
and other tissues and bind to oestrogen and
progesterone receptors, triggering increases or
decreases in the expression of genes regulated
by these hormones, in turn controlling gender,
sexual development and reproduction. When taken
correctly in the contraceptive pill, they interfere
with the normal monthly cycle of a woman,
preventing pregnancy by stopping the ovaries from
releasing an egg, making it difficult for sperm to
enter the womb (by thickening mucus in the cervix)
and making the lining of the womb too thin for a
fertilised egg to implant.
13.1.2 Evidence of environmental harm from 'the
pill'
The American Food and Drug Administration
approved the pill for use in the US in early 1961
and on 4 December 1961, Enoch Powell, then
Minister of Health, announced that it could be
prescribed through the UK National Health Service
at a subsidised price of two shillings per month
(Time, 1961). Take up of the pill was fast. Between
1962 and 1969, the number of UK users rose from
approximately 50 000 to one million (out of an
estimated 10 million users worldwide), generating
an enormous social impact and earning it a place
on the front cover of Time Magazine in April 1967
(Time, 1967) (3). The pill is hailed as playing a
major role in the women's liberation movement
and greater sexual freedom (Asbell, 1995; Goldin
and Katz, 2002). Its availability, particularly in
the developed world, has made a significant
and dramatic impact on women's lives: giving
unprecedented control over fertility, preventing
pregnancy, and so avoiding the mortality and
morbidity associated with pregnancy, childbirth
and termination.
The pill now comes in 32 different forms and is
used by more than 100 million women worldwide.
Usage varies widely by country (UNPD, 2006;
Leridon, 2006), age, education, and marital status.
One quarter of women aged 16–49 in Great Britain
currently use the pill — either the combined pill,
progesterone-only pill or 'minipill' (Taylor et al.,
In the 1970s some scientists began speculating
that using the contraceptive pill might cause
environmental problems (e.g. Tabak and Bunch,
1970). They realised that oral medications,
including contraceptives, are in fact rather
inefficient methods for administering drugs to
the body, since it takes a lot of drug administered
orally to get a little into the bloodstream. The
rest of the medicine passes right through the
body and into wastewater in urine and faeces.
Since water and waste treatment plants were
not designed to remove pharmaceuticals (or
indeed other man‑made chemicals), it was likely
that the contents of our medicine cabinets were
unintentionally being passed on directly into the
environment, and eventually, even into drinking
water supplies.
EE2 is excreted as conjugates of sulphates
and glucuronides, along with the natural
steroid hormones oestrogens oestrone (E1),
17β-oestradiol(E2) and oestriol(E3) that occur
naturally in humans. The synthetic EE2 shares
a common hormonal mode of action with these
natural oestrogens, which also means that, when
released into the environment, the oestrogenic
endocrine disrupting effects of EE2, and the natural
steroid oestrogens in combination are additive.
EE2, the synthetic oestrogen, is however by far the
most potent of the four.
The data supporting the need for risk management
of EE2 and the most potent of the three other
steroid oestrogens (E2 and E1), due to their
endocrine disrupting effects in the environment,
are now comprehensive and compelling (GrossSorokin et al., 2006; Caldwell et al., 2008).
Based on data amassed over many decades, the
mechanism of toxicity of EE2, E2 and E1 is now
well understood. They are continuously, and
widely, released into the aquatic environment
and are persistently present, having a half life
in fresh water of between less than a day and
approximately 50 days under aerobic conditions.
(2) Progestogens (also spelled progestagens or gestagens) are a group of hormones including progesterone.
(3) Front cover of Time Magazine's April 1967 edition can be viewed at: http://www.time.com/time/covers/0,16641,19670407,00.html.
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Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
They have been shown to cause endocrine
disrupting effects at environmentally relevant
concentrations in controlled laboratory studies
(e.g. Lange et al., 2001; Nash et al., 2004, reviewed
in Caldwell et al., 2008), in field studies of fish
placed downstream of sewage treatment works
with various types of secondary treatment
technologies (Harries et al., 1996 and 1997) and in
whole experimental lake studies dosed with EE2
(Kidd et al., 2007).
In some UK rivers, 100 % of wild male fish of the
species Rutilus rutilus (roach, a common freshwater
fish of significance to anglers) sampled between
1995 and 2002 had female characteristics (Jobling
et al., 1998) and intersex has now been reported in
many fish of a number of freshwater and marine
species, in more than 10 countries (Tyler and
Jobling, 2008; Hinck et al., 2009). Models predicting
exposure of riverine fish to EE2, E2 and E1 in the
United Kingdom have also been shown to correlate
well with impacts observed in fish populations
in the field (Jobling et al., 2006). These impacts
damage fish reproductive health, for example
affecting fertility and fecundity (Jobling et al.,
2002a and 2002b; Harries, Hamilton et al., 2011)
and are in some cases irreversible (Rodgers-Gray
et al., 2001).
Risk characterisation of EE2 and the other two
non-synthetic steroid oestrogens, E2 and E1,
in the aquatic environment is possibly one
of the most comprehensive for any chemical
pollutant. Many millions of euro have been
spent on this research over many decades. The
chemical industry has concluded that 'endocrine
disruption is undoubtedly occurring in wild fish
populations' and that the evidence that wildlife
has been impacted adversely following exposure
to endocrine disrupting substances is 'extensive'
(Webb et al., 2003). The pharmaceutical industry, in
particular, has carried out and funded some of the
key lab studies showing that EE2 plays a key role
in causing these effects (e.g. Lange et al., 2001).
In response to this evidence, in 2004 the
Environment Agency of England and Wales (EA)
concluded that risk management was needed for
steroid oestrogens (Gross-Sorokin et al., 2006). In
2012 the European Commission proposed EE2 as
a Priority Substance (i.e. a substance requiring
control across Europe) under the Water Framework
Directive, one of the most important pieces of
legislation for protecting European surface and
ground waters, proposing regulatory limits in
the aquatic environment for EE2. At present,
this is only a proposal, with formal processes of
282
agreement required before regulation can occur.
In July 2012 an amendment to this proposal was
tabled. This delays review of a proposal for a
regulatory limit until 2016 (rather than 2012),
which (if adopted) would then have to be complied
with by 2027. Nevertheless nearly 75 years after its
initial development, during which time some of the
most comprehensive and compelling evidence of
environmental impact for any chemical has been
amassed, a decision to regulate of EE2 is finally
under serious consideration. Why has this taken so
long? And what lessons can we learn?
The example of EE2 and endocrine disruption in
the aquatic environment, and the questions and
dilemmas it raises, is in many ways a test case
for many thousands of low-level pollutants that
infiltrate our environment ubiquitously, many of
which have chronic impacts that go beyond the
acute polluting effects of past industrial chemicals.
13.2 Early warnings
13.2.1 Early warnings from wildlife:
the UK experience
The earliest concerns about possible hormone
contamination of water (from contraceptive pills
and other sources) related to impacts on male fish
reproductive health in UK rivers. In 1978, Tony
Dearsley, a Thames water area biologist in the
United Kingdom, found eggs developing in the
testes of five out of 26 male fish of the commonly
caught species Rutilus rutilus (the roach) while
conducting a routine health check on a small
sample of fish from the River Lea.
As Dearsley's manager, Roger Sweeting, then
Senior Scientist at Thames Water, noted, 'It was
amazing to see macroscopically hermaphrodite
fish that were both male and female all at the same
time'(Sweeting, pers. comm.). It was not until
a year later, however, after reading a paper by
Jafri and Ensor (1979), that Sweeting telephoned
David Ensor, who confirmed that the findings
were highly unusual. Jafri and Ensor had reported
a normal incidence of hermaphroditism of 1 in
1 000, in the same species of fish (Jafri and Ensor,
1979), more than 100 times lower than found in
the fish collected from the Lower River Lea (see
Figure 13.1).
Larger samples of fish confirmed the earlier
observations. It was also observed that the
incidence of feminisation varied with the age of
the fish, with the highest proportion (20 %) found
Late lessons from early warnings: science, precaution, innovation
Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
Figure 13.1 Histological sections showing intersex phenotypes in roach
Note:
Image (1) shows a female-like ovarian cavity in an otherwise normal testis. Image (2) shows a severely intersex gonad
following exposure to sewage effluent with a testis containing a large number of primary oocytes at a single focus.
Image (3) shows the intersex gonad of a wild fish caught from the River Aire, the United Kingdom. Tl denotes 'testis lobule'.
PO denotes 'primary oocyte'.
in the older fish (aged more than six years). Roger
Sweeting reported that this suggested a 'cumulative
effect with time' (Sweeting, 1981).
Thames Water, at the time a government-owned
company, was proactive in researching the
matter further to gain a better understanding of
its relevance to public health. It was reasoned
that 'some risk of endocrine disturbance in
human consumers of the water could be implied'
(Sweeting, 1981) as it was known that the River
Thames received discharges from numerous
wastewater treatment plants (352 according to
Williams et al. (2008)) and that it also served as
a major potable water source for North London.
Water abstracted from the river was purified, used
by people, or industry, and then disposed of to
sewage treatment works, where it was 'cleaned'
before being discharged (as effluent) back into the
river, only to be abstracted, used and cleaned a
second or subsequent time downstream. (For this
reason, it is a commonly said that when you drink
a glass of water in London, the water has already
passed through several pairs of kidneys).
Thames Water's concerns for public health led
to further studies (never published) under a
research contract given to Liverpool University.
Water samples were taken directly from the River
Lea at the drinking water abstraction point and
transported on a train to Liverpool University,
where they were given to rats to drink. Derek
Tinsley (a PhD student at the time who now works
for the Environment Agency of England and Wales)
recalls visiting the station at regular intervals to
collect the water. The studies showed clearly that
giving female rats this water to drink for 12 months
induced persistent oestrous.
Further studies showed, however, that water
samples taken part way through the drinking
water treatment process had no effects on the rats.
Moreover autopsies of small mammals (water
voles and wild rats) trapped around the sewage
works revealed no obvious gross reproductive
abnormalities. Derek Tinsley recalls that he felt
'relief that there were no signs of any effects of
the treated drinking water on the rat reproductive
system, and therefore no apparent risks to the
consumer' (4).
Thames Water officials felt confident enough to
present Tinsley and Ensor's results to a standing
committee of the Department of Health, which,
after conducting further studies, agreed that there
was enough information to discount any possibility
of risk to human consumers of water abstracted
from the Lower Lea. It is striking that such a rapid
decision was made on the basis of this small set of
studies. This, as we will go on to discuss, is in stark
contrast to decision-making regarding protection
of aquatic wildlife from the effects of EE2 and other
oestrogens, despite the many studies indicating
adverse health effects related to oestrogen exposure.
The possibility that the contraceptive pill hormone
might well be causing intersex in fish was not
formally stated in any of the scientific reports
circulated between the government and the water
industry. Nor was any link made with the reports
of occurrence of steroidal oestrogens in wastewater,
river and potable waters (Tabak and Bunch, 1970;
(4) Personal communication from Derek Tinsley.
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Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
Tabak et al., 1981; Aherne et al., 1985). At least
one of those studies had recognised that steroidal
oestrogens could potentially have adverse effects,
even if none were identified:
'the concentrations found are far below
therapeutic doses and there appears to be
no evidence of adverse effects from reused
water resources which may be contaminated
from the normal use of such highly active
therapeutic agents' (Aherne et al., 1985).
Aherne and colleagues could not have known
about the Thames Water studies as they were
confidential. Moreover, the significance of their
work and the earlier studies by Tabak and
colleagues was not recognised, because the human
health agencies responsible for international drug
regulation at the time usually had limited expertise
in environmental issues; consideration of these
was not formally required. The situation is today
very different, with environmental exposure now
recognised as a key consideration (for example in
European Medicines Agency guidelines (EMA,
2006) (5). Moreover, until the 1990s, any concerted
chemical analytical efforts to look for drugs in
the environment achieved limited success. This is
because the requisite chemical analysis tools (with
sufficiently high separatory powers to identify
the drugs amid a plethora of other natural and
anthropogenic substances in the environment, and
sufficiently low detection limits (i.e. nanograms
per litre or parts per trillion)) were not commonly
available.
Now there is considerable concern about the
increasing amounts of pharmaceuticals that are
being consumed and found in the environment
(Kümmerer, 2004 and 2007; Apoteket AB et al., 2006
and 2009; EEA, 2010; German Advisory Council on
the Environment 2007; Mistrapharma, 2011). With
an ageing population the UK Office of National
Statistics predicts that the country's medicine usage
will more than double by 2050 (Nature, 2011).
13.2.2 More evidence of an environmental problem
In the mid-1980s, fisheries scientists working for
the UK Ministry of Agriculture Fisheries and
Food, or MAFF (Dr Colin Purdom, Dr Vic Bye
and Dr Alex Scott) were asked to comment on the
evidence collected to date. Quite independently,
one of their colleagues, Dr John Sumpter, had
found high levels of a female-specific yolk protein
(vitellogenin or VTG) in the blood of male fish
kept at an experimental fish farm rented by MAFF.
VTG is under strict oestrogen control and as males
have extremely low (often undetectable) levels of
oestrogen in their blood, they can only produce
VTG if they are exposed to an oestrogen (Sumpter
and Jobling, 1995). The scientists wondered
whether the fish were being supplied with water
contaminated with oestrogens originating from the
treated sewage effluent entering the river upstream
of the fish farm, and whether oestrogens in the
water might also explain the discovery of feminised
wild male fish in the River Lea.
Field trials in the late 1980s, funded by the
Department of the Environment (DoE), confirmed
that VTG levels in male trout placed for just two
weeks in the sewage treatment plant effluent from
Rye Meads sewage treatment works (which entered
the River Lea) underwent a 100 000 fold increase,
reaching levels equivalent to those in mature
females. These results provided the impetus for a
nationwide survey of effluents (conducted between
1987 and 1990) by Brunel University (John Sumpter
and Charles Tyler) and MAFF (Colin Purdom,
Vic Bye, Sandy Scott and Peter Hardiman), with
funding from the DoE. The results of this survey
proved beyond doubt that oestrogenic effluents
entering rivers were widespread throughout
England and Wales (Purdom et al., 1994).
By the late 1980s, therefore, there was already
evidence that wastewater from sewage treatment
plants was having harmful effects on aquatic
wildlife, and that at least one possible culprit was
EE2. This information was not widely circulated
beyond government and industrial organisations.
Indeed, the results were not published until 1994
(Purdom et al., 1994), because of the contractual
agreement between the DoE, MAFF and Brunel
University. There was little action: policymakers
of that era perhaps preferred to wait until the level
of proof linking cause with effect was beyond
reasonable doubt, reflecting a wider resistance at
the time to precautionary action in the absence of
higher levels of proof.
Subsequent research has proven EE2's presence in
effluents and natural waters, and established that it
(5) More recent guidance from the European Medicines Agency states that if the estimated environmental concentration (i.e. predicted
surface water concentration) of a medical product is below 0.01ppb and 'no other environmental concerns are apparent' then no
further actions are needed in terms of environmental risk assessment, i.e. no action needed by a pharmaceutical company.
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Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
is highly likely that it is contributing significantly
to the damaging effects seen in wild fish (Caldwell
et al., 2009). Moreover, studies carried out in
Canada have confirmed large effects associated
with very low concentrations in a multi-year study
in which fish living in a large experimental lake
were exposed to introduced EE2 (Kidd et al. (2007):
6.1 ng/L (+/– 2.8) during the first year, 5.0 ng/L
(+/– 1.8) during the second year and 4.8 ng/L
(+/– 1.0) during the third year of. This low level
introduction of oestrogen provoked a large surge
in fish plasma VTG levels, followed by complete
collapse of the fish population. The fundamental
conclusion, that EE2 and other hormones in
wastewater, both natural and synthetic, are
harming aquatic wildlife, particularly downstream
of wastewater plants with low dilution, has not
changed since the late 1980s. Only the level of
uncertainty has reduced.
13.2.3 Widespread endocrine disruption in wild
fish and growing evidence of problems in
other wildlife
The discovery in the 1980s that oestrogenic
effluents were widespread led logically to more
caged fish trials that illustrated the extent of the
oestrogenic pollution at greater distances from the
sewage treatment works (Harries et al., 1996 and
1997). Extensive field trials in the United Kingdom
between 1995 and 2000 also showed unequivocally
that intersex in wild roach was widespread and
especially prevalent up to 10 km downstream of
medium- to large-sized sewage treatment works
(serving populations of 50 000 to 675 000) and
where dilution of their effluents in receiving river
waters was less than 10-fold (Jobling et al., 1998).
In addition, studies on estuarine species of fish
illustrated clearly that the effects of oestrogenic
contaminants extended beyond the rivers into
estuaries (Lye et al., 1997 and 1998; Allen et al.,
1999) Feminisation and sub-fertility were also
reported in additional wildlife species, especially
those living in or around the aquatic environment
(reviewed in Lyons, 2008). Specifically:
• amphibians were found to have abnormal
production of VTG by males and ovotestes/
intersex features;
• reptiles were found to have abnormal production
of VTG by males: sex hormone disruption;
ovotestes; smaller phallus in alligators and shorter
estimated penis length in turtles; decreased
hatching; and decreased post hatch survival;
• birds were found to have abnormal VTG
production in males; deformities of the
reproductive tract; embryonic mortality; reduced
reproductive success including egg-shell thinning
and poor parenting behaviour;
• otters and mink were found to have reduced
penile bone length; smaller testes; and impaired
reproduction;
• seals and sea lions were found to have impaired
reproduction (including implantation failure,
sterility, abortion, premature pupping);
• cetaceans were found to have reduced
testosterone levels; impaired reproduction; and
hermaphrodite organs;
• polar bears were found to have intersex features
and deformed genitals; reduced testes and
baculum length; low testosterone levels in adult
males; and reduced cub survival.
In none of these cases was a link with exposure to EE2
investigated and/or proven.
13.2.4 Wildlife as sentinels for human reproductive
health
Beyond the aquatic environment, the feminising
syndromes found in wildlife appeared to mirror
reports of male infertility, genital abnormalities
and testicular cancer observed in the human male
population, collectively termed Testicular Dysgenesis
Syndrome (TDS; see Box 13.1). If testicular dysgenesis
syndrome was occurring in humans due to
environmental pollutants, then genital disruption
should have been found in wildlife exposed to
those pollutants. This did indeed seem to be the
case. The question arose whether the effects seen
in wildlife and in humans shared a common cause:
environmental oestrogens including EE2. There had
already been evidence of human health impacts
associated with another synthetic oestrogen created in
the same year as EE2: diethylstilbestrol (DES). From
the 1940s to the early 1970s, pregnant women in the
US (and beyond) were commonly prescribed DES in
the mistaken belief that it could prevent miscarriage.
Some of the sons of these DES mothers developed
low sperm counts, undescended testicles and
deformations of the penis (Ibaretta and Swan, 2001).
The steepest declines in male reproductive health
appear to have taken place in most countries between
the 1960s and the 1980s, coinciding not only with
the introduction and take up of the contraceptive
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Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
Box 13.1 Human health concerns
The first indications that something might be wrong with human sperm came in 1974, when Kinloch Nelson
and Bunge produced a small study of the semen quality of men who were about to undergo vasectomies.
They found that only 7 % had sperm concentrations above 100 million (Kinloch Nelson and Bunge, 1974),
which is well below the 65 % reported earlier by pioneering andrologist, John Macleod (MacLeod and Heim,
1945).
Kinloch Nelson and Bunge speculated that 'an environmental factor to which the entire population has been
exposed' might be causing the low sperm counts. These studies were discredited by John MacLeod himself
in 1979. While acknowledging a decline in sperm counts in fertile males since the 1930s, MacLeod and
Wang (1979) rejected the notion of a larger, overall decline, citing analytical errors in the Nelson and Bunge
study and suggesting a concentration of 20 million per ml should be the lower limit for the normal sperm
count. This limit was adopted in the WHO guidelines for semen analysis in 1980 (WHO, 1980).
Nothing more was reported until 1992, when Danish clinician Niels Skakkebaek and Elizabeth Carlsen
published their ground-breaking paper on studies of sperm counts around the world. In 61 studies going
back as far as 1938, they found a decline in average sperm density from 113 million per millilitre in 1940
to 66 million in 1990 (Carlsen et al., 1992). These findings made some scientists wonder whether the
human species was approaching a fertility crisis. Debate on this issue was intense and opinion was divided
regarding the validity of the apparent fall in global sperm counts (e.g. Swan et al., 1997; Paulsen et al.,
1996; Fisch et al., 1996).
The approach taken in Europe (led by Skakkebaek) followed the reasoning that 'if sperm counts have fallen
then the average should be lower in men born most recently than they were in the past'. More recent
investigations in seven European countries involving more than 4 000 young men have shown that in
most of the countries investigated 20 % or more of young men have a subnormal sperm count (less than
20 mn per ml) and the average sperm count is 45–65 million (Jorgensen et al., 2006). This is consistent
with sperm counts having fallen, as suggested by the meta-analysis studies. More importantly, it shows that
male subfertility is likely to be a common issue for current and future generations, with widespread societal
and economic consequences.
The importance of declining semen quality lies partly in its possible link with other problems of male
reproductive organs, especially the rise in the incidence of testicular cancer (Adami et al., 1994;
Wanderas et al., 1995; Bergstrom et al., 1996; Moller, 2001; McGlynn et al., 2003; Richiardi, 2004)
and in congenital malformations of the male reproductive system such as cryptorchidism (undescended
testis) and hypospadias (penis malformation) (Hohlbein, 1959; Sweet et al., 1974; WHO, 1991; Matlai
and Beral, 1985; Paulozzi et al., 1997; Lund et al., 2009). These diseases often occur together (Prener,
1992; Berthelsen, 1984; Petersen et al., 1999; Schnack et al., 2009) and may have the same underlying
pathology — testicular dysgenesis syndrome (TDS) (Sharpe and Skakkebaek, 1993; Skakkebaek, 1998)
with a common origin in fetal life (see Figure 13.2).
Figure 13.2 Testicular dysgenesis syndrome
Environmental factors
incl. endocrine disrupters
Disturbed
sertoli cell
function
Impaired
germ cell
differentiation
Reduced
semen quality
CIS
Testicular
dysgenesis
Testicular cancer
Hypospadias
Genetic defects
incl. 45,X/46,XY and
point mutations
Decreased
leydig
cell function
Androgen
insufficiency
Testicular maldescent
Source: Sharpe and Skakkebaek, 1993.
286
Reduced
fertility
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Box 13.1 Human health concerns (cont.)
Unlike in the case of intersex in fish, there has never been one widely accepted theory regarding the cause
of the decline in male reproductive health. Instead, a bewildering array of hypothetical culprits have been
posited, including not only the residues of birth control pills in drinking water or inadvertent pill taking during
pregnancy, but also a range of anti-androgenic industrial chemicals (male hormone lowering or blocking)
and non-chemical stressors that have been shown in laboratory studies to induce TDS when exposure takes
place during early pregnancy (Sharpe, 2009). The research in this field has been challenged by the lack of
human exposure information and the absence of results of past testing of industrial chemicals for endocrine
disruption and other adverse effects that may affect the development of the male reproductive system. Even
if animal testing is performed, the results cannot directly be translated to humans because, for example, a
chemical may reduce sperm counts by 80–90 % in rats before male fertility is affected.
The net result is that no systematic effort has been made to prevent infertility, despite the substantial
potential societal consequences associated with its widespread occurrence. Indeed, the official WHO
response to male infertility has been to redefine the ill people as 'normal' by changing the lower reference
value for a 'normal' sperm concentration first from 60 mn/ml in 1940s to 20 mn/ml in 1980 and then to the
current 15 mn/ml (WHO, 2010), making it of little use in helping society recognise that there is a problem
(Skakkebaek, 2010).
pill but also with the entry of many other synthetic
chemicals into the environment, the Clean Water
Act in 1972 and subsequent upgrading of sewage
treatment plants to secondary treatment. Thus,
endocrine disruption in the developing child could
have occurred through the inadvertent consumption
of pills in the first trimester of pregnancy (Smithells,
1981, although refuted by Joffe, 2002). Alternatively,
or additionally, it could have resulted from drinking
water containing residues of contraceptive pill
hormones and a whole plethora of industrial
chemicals. Or it could have resulted from inadvertent
exposure to these chemicals via application to the
skin (cosmetics), inhalation or diet. A more recent
report highlights a relationship between modern
contraceptive pill use and prostate cancer (Margel
and Fleshner, 2011), another hormone-dependent
male reproductive disease.
In the case of the contraceptive pill, one might
expect the exposure to have been higher in the 1960s,
1970s and 1980s than in later years as the first pill
formulations contained up to 100 μg of oestrogen, at
least five times higher than current formulations. If
exposure to the contraceptive pill was a significant
risk factor in causing TDS, the effects should show up
in statistics on male reproductive health.
Examination of historical contraceptive pill usage in
various countries does indeed suggest higher rates of
use (allowing a 30–35 year time lag between exposure
of the developing child and the later appearance of
testicular cancer) in some countries where rates of
testicular cancer and hypospadias are higher, such as
Denmark, Germany, Hungary, the United Kingdom
and USA, than in countries where rates are lower,
such as Bulgaria, Finland, Italy, Poland, Portugal,
Romania and Spain and Japan (Leridon et al., 2006).
These associations may well be coincidental, however,
as the available evidence in support of the oestrogen
theory is not entirely convincing (Raman‑Wilms
et al., 1995; Toppari et al., 1996; Martin et al., 2008).
Indeed, recent animal experimental studies suggest
that industrial chemicals that block the action of male
hormones (anti-androgens) are more likely culprits
of declines in male reproductive health and could
even act in combination with oestrogens to induce
a proportion of the cases of TDS seen in humans.
So far, however, 'there is no human or experimental
animal data to support this' (Sharpe, 2009). The lack
of cause-effect, especially in human epidemiological
studies, could easily be wrongly interpreted as ruling
out involvement of endocrine disruptors in TDS.
Several factors complicate analysis, including the
long latency between exposure and effect and the
possibility that the effects may be caused by multiple
chemicals in combination, while exposure to each
chemical individually may not be insufficient to cause
damage. This is also why Bradford Hill's criteria,
when invoked in the 2002 WHO report on endocrine
disruption (WHO, 2002), rejected the hypothesis
of an impact on male reproductive function. These
criteria are not suited for determining causation by
environmental toxicants because such exposures are
simply too complex. Perhaps we should abandon the
unrealistic hope of achieving more certainty prior to
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policymaking about human male reproductive health
and use wildlife as sentinels instead?
The case for endocrine disrupting chemicals causing
male sterility in humans and wildlife, showing
wildlife were sentinels for human health, was
beautifully presented in the British Broadcasting
Company's award-winning Horizon documentary
'Assault on the male', written and produced by
Deborah Cadbury and screened in 1993. The world
began to sit up and take notice. Mounting concern
in Europe was such that between 1998 and 2007 the
European Commission invested over EUR 150 million
into researching endocrine disruption. This research
provided the basis for testing both existing chemicals
and those planned for introduction to the market
in the future for their endocrine disrupting effects.
It also furthered understanding of the effects
of mixtures of endocrine disrupting chemicals,
identification of vulnerable life stages and impacts
on male reproductive health. The new data showed
that a wide range of chemicals could have endocrine
disrupting effects, with a wide range of health
impacts.
13.3 The hunt for the culprit chemicals
Against the backdrop of growing global awareness
of endocrine disruption, attention focused on the
chemicals responsible for the feminised male fish
observed in UK rivers. Laboratory studies showed
clearly that male fish were extremely sensitive
to the presence of EE2 in the water at low ng/L
concentrations (Sheahan et al., 1994). Until the
mid‑1990s, however, few were convinced that this
or any other hormone was present in wastewater in
sufficient amounts to cause the effects seen in fish.
Coincidentally, during that time information
was emerging from the US that, in addition to
pharmaceuticals, industrial chemicals in everyday
use could mimic oestrogens. Although this was first
shown by Charles Dodds in the 1930s (Dodds et al.,
1936), widespread awareness of this possibility was
instigated by John McLachlan, one of the pioneers
of research into environmental oestrogens and the
organiser of the first meeting on the topic in 1979
(McLachlan, 1980).
It now seemed possible that effects seen in
aquatic and other wildlife were actually more
likely to be a result of exposure to cocktails of
'endocrine‑disrupting' industrial chemicals,
(Clement and Colborn, 1992) than to the
contraceptive pill hormone. In 1988 Theo Colborn,
in her research on the environmental condition
of the North American Great Lakes, showed
that persistent, man‑made chemicals were being
transferred from top predator females to their
offspring, undermining the construction and
programming of their youngsters' organs before
they were born. In 1991, Theo convened a meeting
('The Wingspread Meeting') of 21 international
scientists from 15 different disciplines to share
relevant research on the topic and it was during
this meeting that the term 'endocrine disruption'
was coined.
It was also in 1991 that Dr Ana Soto published a
paper about the oestrogenic effects of nonylphenol,
a chemical compound used in manufacturing a
large group of industrial detergents (Soto et al.,
1991). Some detective work by Susan Jobling (then
a student of John Sumpter) at Brunel University
revealed that the environmental chemist Walter
Giger had identified these chemicals in sewage
treatment works effluents, sewage sludge and river
water (Giger et al., 1984) at concentrations that
Jobling later confirmed were oestrogenic to fish
exposed to the chemicals in the laboratory (Jobling
and Sumpter, 1993; Jobling et al., 1996).
An earlier report of the oestrogenic activity of
4-nonylphenol, was published in 1936 by Charles
Dodds when he was trying to synthesise one of the
first synthetic oestrogens, diethylstilbesterol (6).
The detergent industry may have been unaware of
this literature when it embarked on the largescale
manufacture and sale of nonylphenol ethoxylates
as detergents in the 1940s, leading to the
contamination of many rivers and estuaries with
these oestrogenic chemicals.
While the causal links between exposure to
industrial chemicals and endocrine disruption
in most wildlife species were still unclear in the
1990s, further research in the United Kingdom
and other European countries showed that
nonylphenolic chemicals were causing at least part
of the problem in wild fish in some, but not all,
areas (Sheahan et al., 2002a and 2002b). However,
more sophisticated studies employing chemical
fractionation and screening of effluents using an
in vitro oestrogenicity screen showed that naturally
occurring and synthetic steroid oestrogens (EE2, E2
(6) Interestingly, Dodds identified another controversial compound at the same time — the environmental endocrine disruptor
bisphenol-A (Dodds, 1938). See also Chapter 10 on BPA.
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Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
and E1) were in fact the most potent oestrogenically
active substances present in domestic effluents
(Desbrow et al., 1998; Routledge et al., 1998;
Snyder et al., 2001), responsible for much of the
oestrogenic activity found in wastewaters and
rivers throughout most of the world. Of these, EE2
was by far the most potent: the pill was once again
under the spotlight.
13.4 Government and industry action in
the 1990s
Enormous efforts were made in the 1990s to assess
and manage the risks of alkyphenols, not only
because of their endocrine disrupting effects but
also their wider toxicity to aquatic life:
Following recommendations of the UK Chemicals
Stakeholder Forum, the UK government negotiated
a voluntary agreement with the suppliers of
nonylphenols, octylphenols, and their respective
ethoxylates. Suppliers thereby agreed not to
promote octylphenol (another endocrine disruptor
also found in sewage effluent) as a substitute
for nonylphenols, not to manufacture or import
new formulations or products containing those
substances, and to reformulate existing products
to remove those substances as a matter of urgency.
This was a constructive application of the
precautionary principle (Lokke, 2006), which has
not been extended to EE2.
Similarly, in mainland Europe, the European Union
undertook a risk assessment of nonylphenols and,
as a result, restrictions on using nonylphenol have
been imposed across Europe.
At the same time, continued uncertainty about
exposure to chemical pollutants in the environment
and their effects on the human population
(particularly regarding reproductive health)
were highlighted during discussions at a major
European workshop at Weybridge, the United
Kingdom (7), on endocrine disrupting chemicals
held in December 1996 and jointly sponsored by the
European Commission, the European Environment
Agency, the European Centre for Environment and
Health and the WHO (EU, 1996). An EU strategy
on endocrine disruptors was launched in 1999 to
begin to address the problem (EU, 1999) but still no
action was taken on EE2.
13.5 The last decade of research
Since the mid-1990s, oestrogenic sewage-treatment
works effluents have been identified more widely
across Europe, and globally, e.g. in Denmark
(Bjerregaard et al., 2006), Germany (Hecker et al.,
2002), the Netherlands (Vethaak et al., 2005),
Portugal (Diniz et al., 2005), Sweden (Larsson et al.,
1999), Switzerland (Vermeirssen et al., 2005), China
(Ma et al., 2005), Japan (Higashitani et al., 2003)
and the United States (Folmar et al., 1996). More
extensive evidence has also emerged from around
the world showing widespread endocrine disruption
in fish in rivers (Hinck et al., 2009; Bjerregaard et al.,
2006; Blazer et al., 2007; De Metrio et al., 2003; Hinck
et al., 2009; Penaz et al., 2005; Vajda et al., 2008),
estuaries (Allen et al., 1999) and oceans (Cho et al.,
2003; Ohkubo et al., 2003; Fossi et al., 2004; Kirby
et al., 2004; Scott et al., 2006 and 2007).
In general, the situation in other countries appears
to match that found in the United Kingdom. The
incidence and severity of endocrine disruption
appears to relate largely to the size of the sewage
works (treatment type is also important), most
importantly, and the dilution of its effluent in
the receiving water. This leads to generally lesser
effects in fish inhabiting large rivers with high
dilution factors (a common scenario in the US and
parts of Europe, for example) compared with those
in smaller rivers with little dilution (a common
scenario in the United Kingdom and other parts
of Europe). In Japan, where contraceptive pill
hormone use is probably the lowest anywhere in the
developed world and where endocrine disruption
in fish is reported to be quite rare (Tanaka et al.,
2001; Higashitani et el., 2003), the greater mean river
flow, and hence available dilution per capita (five
times more than in the United Kingdom), suggests
that combined steroid estrogen potency will be
less across its rivers than in the United Kingdom.
Even if the Japanese population were to take up the
contraceptive pill to the extent of use in England
then widespread endocrine disruption in fish would
still not be predicted because of the large amount of
available dilution (Johnson et al., 2012).
A growing body of evidence also shows that the
harm caused by exposure to endocrine disrupting
chemicals early in development is, in many cases,
irreversible. In fish, as in humans and rodents,
feminisation of the male reproductive tract occurs
early in development and produces a fish with
(7) In 2006 the 10th anniversary of Weybridge was marked with a conference organised by the Academy of Finland, the European
Commission (DG Research), and the EEA. The EEA has updated and published the papers from that meeting (EEA, 2012).
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289
Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
both an oviduct and a sperm duct. Depuration
in clean water does not correct this condition,
indicating that feminised ducts seen in wild roach
are likely to be a permanent feature (Rodgers-Gray,
2001). Considerable evidence also shows that both
the prevalence and the severity of feminisation
in wild roach increases with age (Jobling et al.,
2006), in extreme cases resulting in a 100 % female
population after three years of continuous exposure
to treated sewage effluents or EE2 (Lange et al.,
2009).
Population-relevant effects of EE2 have also been
documented, including a complete fish life cycle
test carried out by the original manufacturers of
EE2, Schering (Lange et al., 2001), which showed
inhibition of breeding at concentrations exceeding
the environmentally relevant concentration of
2 ng/L and full sex reversal of males producing
an all female population at 4 ng/L. This effect was
corroborated by Kidd et al., (2007), who (as we
have already noted) dosed an entire lake with EE2,
causing a population collapse at concentrations of
approximately 5–6 ng/L.
Improvements in analytical power, lower analytical
instrument detection limits and innovative
modelling approaches have led to the discovery of
other steroid oestrogens in the environment, such
as equine oestrogens used in hormone replacement
therapies (Tyler et al., 2009). There are now also
more accurate measurements (Williams et al.,
2003; Kanda and Churchley, 2008) and credible
modelled estimates (Hannah et al., 2009) of steroid
oestrogen concentrations present in sewage effluents
and in rivers . This has caused a mixture of doubt
and amazement at the possibility that EE2 could
be causing endocrine disruption at the very low
concentrations at which it is present.
The last decade has also brought the realisation
that risk assessments for mixtures of hormonally
active chemicals are not adequately protective if
based on data for individual substances. Mixtures of
synthetic and natural oestrogens (EE2, E2, E1) each
at or below their individual 'no effect' concentration
were shown to be particularly potent when present
in combination (Silva et al., 2002; Thorpe et al., 2003;
Brian et al., 2005 and 2007) or with other industrial
chemicals with anti-androgenic (male-hormone
blocking) activity. These findings confirmed
concerns originally mooted by Rachel Carson in
1962 in her book, Silent Spring.
More recent reports show an almost concurrent
incidence of anti-androgenic chemicals and
oestrogens in treated wastewater throughout the
290
United Kingdom. Statistical modelling of exposure
and effect data suggest that these chemicals (although
not yet identified) could play a pivotal role in causing
feminising effects in male fish in UK rivers. Until now
it was thought that such effects were caused only by
oestrogens found in contraceptive pills and some
industrial chemicals (Jobling et al., 2009).
There may be a further twist in the story. Synthetic
progesterones (which complement synthetic
oestrogen in the contraceptive pill) have been
identified in natural waters (Standley et al., 2008;
Kuster et al., 2008) and reported to cause effects in
fish when present at ng/L concentrations (Paulos
et al., 2010; DeQuattro et al., 2012). Ironically, despite
the history of their combined use, oestrogens
and progesterones have yet to be tested in fish 'in
combination', despite the fact that human females
have been carrying out this 'test' for 50 years.
13.6 From risk assessment to risk
management
In 2004, some 25 years after initial observations
of intersex in fish, the UK government accepted
the weight of evidence that EE2, E2 and E1 in
combination posed a significant risk to aquatic
life through their endocrine disrupting effects
(Gross‑Sorokin et al., 2006). The long journey to
this point was passionately championed by Geoff
Brighty, Science Manager at the Environment Agency
of England and Wales. His team, in collaboration
with others, built and defended the evidence-based
case against steroid oestrogens and other endocrine
disrupting chemicals in UK rivers.
As Brighty remarked in 2004, 'We now have enough
data to act as a policy trigger for taking action'
(ScienceBlog, 2004).
End-of-pipe treatment of effluent by water companies
was chosen as the risk management approach,
in comparison to alternative approaches (such as
pharmaceutical industry action to develop substitutes
for the active ingredient (EE2) in the pill). This may
have partly reflected awareness of the public health
benefits of the oral contraceptive, the fact that both
naturally‑excreted and synthetic oestrogens posed
risks via their endocrine disrupting effects (i.e. that
both would need to be removed) and that other
priority hazardous chemicals would also be reduced
with the end-of-pipe treatment approach.
This would place the responsibility for risk
management on the water industry and (ultimately)
the cost of treatment of the tax paying public. In
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Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
2007 the Environment Agency began to develop a
(draft) technical environmental quality standard
(EQS) — a target concentration which could be
used for regulatory compliance for EE2- based on a
predicted no effect concentration of 0.1ng/L (Young
et al., 2004, Figure 13.3). The Environment Agency
also identified the EU Water Framework Directive
(WFD) as an appropriate legislative mechanism
within which the EQS could be enforced. Options
for control under the WFD might be to propose EE2
either as a nationally important 'specific pollutant,
or an EU-wide 'priority substance' requiring control
across Europe. The WFD is the most important
EU legislation for managing water resources
and had already been used to regulate other
endocrine disrupting chemicals such as TBT and
nonylphenol. Since additional endocrine disrupting
chemicals were likely to be proposed as 'specific
pollutants' or 'priority substances' in order to
decrease their overall environmental burden, this
was a reasonable option for the steroid oestrogens.
At this point, no other country in the world had
Environmental Quality Standards for any of these
substances (8).
was budgeted at GBP 25–40 million and was
not welcomed by the UK water industry, which
financed most of the costs. All ten water companies
in England and Wales were involved.
In the first phase of the programme fourteen sewage
treatment plants were used to evaluate the efficiency
of oestrogen removal through 'conventional'
treatment technologies. These consisted of primary
or chemically aided primary sedimentation with
secondary treatment by nitrifying, non-nitrifying
activated sludge (ASP) or biological filtration and
in some cases tertiary sand or biologically aerated
filtration. In the second phase, two so‑called
'full-scale' plants were used to evaluate the most
promising new technology as an additional
Figure 13.3 UK rivers and streams exceeding
the Predicted No Effect
Concentration (PNEC) for EE2
Before introducing risk management of this type
there is an important step known as risk evaluation,
which quantifies the wider consequences and costs
to society of the proposed management approach
and balances them against the benefits. The various
options on how to proceed are then evaluated
and a decision made. For example, a regulatory
impact assessment may be undertaken to evaluate
the implications of bringing in regulation and
implementing an EQS.
In the case of EE2 and the other two steroid
oestrogens it was necessary to understand the
efficiency of various treatment approaches in
removing these substances from sewage treatment
plant final effluents. The approaches included both
existing and new (advanced) treatment methods:
these would need to be quantified in terms of both
financial and carbon costs.
In 2004 the UK water industry, in collaboration
with the Environment Agency and the
UK government, and under the watchful eye of
the independent auditor Ofwat, commenced a
comprehensive and lengthy work programme
to address this goal. The so-called 'National
Demonstration Programme' (Gross-Sorokin, 2006)
Note:
In rivers and streams coloured red the suggested
Predicted No Effect Concentration (PNEC) for EE2
of 0.1 ng/L is exceeded. In rivers coloured green
the combined concentrations of steroid oestrogens
(in EE2 equivalents) are less than the suggested PNEC.
(8) In the US, for example, the FDA regulates pharmaceutical manufacture and the EPA regulates discharge under the Clean Water Act.
However, these limitations may not be strict enough to protect the environment because they are technology-based and do not rely on
environmental data. As explained later, there is no treatment technique currently available that comprehensively deals with EE2.
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Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
advanced tertiary effluent treatment: granular
activated carbon (GAC).
The first phase of the Demonstration Programme
was completed in mid-2008 (UKWIR, 2009). Results
showed that while existing treatment approaches
were effective for removal of oestrone and oestradiol,
particularly using nitrifying activated sludge
treatment, EE2 was far harder to remove. The most
efficient treatment, nitrifying ASP, removed some
54 %, with tertiary treatments accounting for a further
reduction of 0–38 % of that remaining, depending on
the form of tertiary treatment.
These results are completely in line with the
consensus seen in current international scientific
literature, as comprehensively reviewed by Racz and
Goel (2010). Wastewater treatment plants with long
retention times (greater than 10 days), especially
those performing nitrification, seem to be generally
more effective at removing oestrogens because they
allow the enrichment of slow-growing bacteria,
such as nitrifying bacteria, and the establishment
of a more diverse ecological community including
species capable of degrading EE2. For this reason,
expensive membrane bioreactors with microfiltration
and ultrafiltration as well as long retention times
have been shown to effectively degrade and reduce
the concentrations of oestrogens in effluents,
including EE2.
In general, however, EE2 is not nearly as easily
biologically removed as the other oestrogens. The
ethinyl group of EE2 is thought to hinder EE2
sorption and metabolism. Furthermore, EE2 often
exists in the aquatic environment at concentrations
below those at which a substrate can support bacterial
growth. Biodegradation studies at EE2 concentrations
greater than those found in natural environments
(mainly conducted at such concentrations due
to limitations in analytical chemistry techniques)
may therefore lead to erroneous conclusions about
the occurrence, rates and products of microbial
transformation of EE2 and the other steroid
oestrogens.
As a consequence of removal inefficiencies, the
proposed EE2 Predicted No Effect Concentration
(PNEC) of 0.1 ng/L is exceeded in many UK final
effluents entering the aquatic environment,
irrespective of conventional treatment type (see
Figure 13.3). The results of the second phase of the
UK Demonstration Programme were reported in
May 2010 (NDP, 2010). They showed that additional
treatment using a novel approach called granular
activated carbon (GAC) can be effective at removing
EE2, producing final effluents below the EE2 PNEC
292
and with no significant induction in fish VTG or
intersex (Filby et al., 2010; Baynes et al., 2012). GAC
could therefore offer the most promising route for
preventing EE2's entry into the aquatic environment
at harmful levels (noting that in one study
reproduction in fish was slightly, but significantly
impacted by effluent subjected to GAC treatment).
The Demonstration Programme showed, however,
that GAC suffers from a fundamental problem: it is
expensive to implement.
For a small town with a 50 000 population
equivalent (PE) sewage treatment plant, the capital
costs alone of setting up additional GAC were
calculated as being over EUR 3 million. That rose to
over EUR 8 million for a 250 000 PE works serving a
large town such as Swindon, which was one of the
sites chosen in the United Kingdom for assessing
the technology. Operating costs per annum were
calculated as being EUR 800 000 for a 250 000 PE
sewage treatment plant, but this would depend
on the life of the granular activated carbon. Costs
were calculated to approximately 14 kg of CO2 per
person per year. Provisional estimates by the UK
government showed that, in total for England and
Wales, this would translate into costs of between
EUR 32 and 37 billion for the approximately
1 360 sewage treatment works that would require
additional treatment (Owen and Jobling, 2012).
Again, these findings are in line with the findings
of Racz and Goel (2010), who concluded that 'Much
attention has also been placed on studying methods
of removing oestrogens prior to discharging
effluent or disposing waste sludge. While advanced
treatment systems such as chemical removal,
activated carbon, chlorination, ozonation, ultraviolet
irradiation, membrane separation, and other novel
approaches may be effective, their current capital
and operation costs may make them not viable
options.'
Faced with this information, those tasked with
implemention of an EQS for EE2 (for example as
a 'priority substance' under the Water Framework
Directive, see below) increasingly began to worry
about two important considerations: technical
feasibility and disproportionate cost. It confirmed
what they had suspected for many years: EE2 was
potent and hard to get rid of.
Evaluation of risk management costs, which
have to be calculated at a national scale given
the widespread nature of endocrine disruption
(Figure 13.4), is however only one half of the cost
benefit equation. They must be balanced against the
(often intangible) benefits of risk management to
key stakeholders, such as the angling community,
Late lessons from early warnings: science, precaution, innovation
Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
Figure 13.4 Extent of sexual disruption in
roach in English rivers
North East
Midlands
Anglian
Thames
Southern
0%
Note:
1–20 %
21–40 %
41–60 %
61–80 %
81–100 %
Intersex was present at 44 (86 %) of 51 sites
surveyed, with an aggregate incidence of intersex of
23 % of sampled males. Coloured symbols indicate
incidence of intersex at the different river sites
surveyed.
Source: Taylor et al., 2005.
and the public, who will ultimately have to pay
for it. This has been a highly contested and often
acrimonious area of debate, with highly charged
discussions about what constitutes harm at the
level of individual fish and what it means for (more
ecologically important) fish populations. Adding
to this debate is the fact that the costs associated
with removing EE2 and E2 should not be seen in
isolation: treatment such as GAC would also quite
possibly serve to reduce/remove other substances
posing risks to the environment and requiring
control. Why should such removal costs not be
considered for all such chemicals as a whole: is it
scientifically incorrect to blame just EE2 for the
costs?
Another consideration is how such costs might
scale at an EU-wide level, where EU-wide
regulation might occur. One European Commission
estimate for this is EUR 11–18 per person per
annum (EC, 2012). EUREAU (European Federation
of National Associations of Water and Wastewater
Services) however estimates that these costs
are much higher; 25–50 % of the current annual
sewerage charges per year (EUREAU initial position
paper on amending Directives 2000/60/EC and
2008/105/EC as regards priority substances in the
field of water policy). There is clearly considerable
uncertainty here.
The costs at an individual country level are likely
to vary on a country by country basis, for example
varying with the population density, status of
wastewater treatment and size of rivers. In some
cases individual country costs may be substantially
lower than those estimated for the United Kingdom
(e.g. see EU project Neptune and the Swiss project
Micropoll; Eawag, 2009). Many European countries
have lower population densities and much greater
dilution of effluents in their receiving rivers than
seen in the United Kingdom. Consequently, the total
national costs of complying with any regulation
concerning EE2 could be considerably lower in these
countries than in the United Kingdom. In addition,
the quality of treatment plants in mainland Western
Europe is in general higher than in the United
Kingdom. In Germany, for example, most sewage
treatment plants have three stages and some even
have a fourth stage, whilst in the United Kingdom,
two stages are most commonly encountered. As
we have already noted, the addition of a third
stage, whether it be GAC, mild ozonation or simple
sand filtration could cause dramatic reductions
in estrogen concentrations and their biological
effects on fish. As recently demonstrated by Baynes
et al. (2012) using biological effects rather than
chemical concentrations as measures of effective
risk reduction, sand filtration following activated
sludge treatment was almost as effective as GAC at
preventing the feminisation of male fish albeit it was
two thirds cheaper.
For a number of years the decision of whether or not
to regulate EE2 appeared to stall in the still waters of
cost-benefit analysis, with little chance of resolution
and little movement forward. Then, in January 2012,
the European Commission proposed a revised list
of 'priority substances' for the Water Framework
Directive (EC 2012). This included the oestrogens
17β-oestradiol and 17α-ethinyloestradiol. The
proposed regulatory EQS for EE2 was 0.035 ng/L
for inland surface waters (e.g. rivers and lakes):
this is the annually‑averaged limit in these water
bodies. If this proposed EQS is adopted (a first
vote on which occurs in the European Parliament's
Environment, Public Health and Food Safety
Committee in November 2012), it could be taken
into account in the 2015 updated River Basin
Management Plans and associated 'Programmes of
Measures' across Europe, with enforcement required
by 2021. But even now, nearly 75 years after its
Late lessons from early warnings: science, precaution, innovation
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Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
initial manufacture in 1938, and decades of research
concerning its environmental endocrine disrupting
effects, this remains a proposal requiring agreement:
the decision to regulate or not is yet to be made and
may be stalled by recent representations to the EC
from both the water and pharmaceutical industries
(EUREAU, 2012).
Indeed in July 2012 an amendment to this proposal
was tabled, stating 'It is appropriate not to specify
the EQS for certain substances of pharmaceutical
relevance that have been added to the list of priority
substances' and that 'The Commission should
propose the EQS for these substances in the next
review of the list in 2016, and appropriate measures
should be introduced…with the aim of meeting the
EQS by 2027' (9).
13.7 Late lessons
Ethinyloestradiol, the active ingredient in the
birth control pill, has allowed women to control
their fertility reliably on a global scale. But it has
come at a price to the environment. As mixtures,
EE2 and other oestrogens, both synthetic and
natural, have been shown to have serious impacts
on wildlife — impacts that can be associated with
early life exposure but manifest themselves later
in adult life. Such impacts are often sub-lethal but
may be permanent and irreversible. They may also
serve as sentinels for impacts on human health
via environmental oestrogen or other endocrine
disrupting chemical exposure.
Since wildlife is exposed to a cocktail of endocrine
disrupting chemicals, it is naive to conclude that
EE2 alone is the culprit. It is, however, the most
potently oestrogenic of the steroid oestrogens,
occurring widely in effluents entering the
environment, at concentrations that can frequently
exceed the Predicted No Effect Concentration
of 0.1 parts per trillion (UKWIR, 2009). There is
reasonable certainty, based on sufficient scientific
evidence, that EE2 plays a significant role in
causing the reproductive health impacts observed
in fish. The need for risk management has been
accepted by both the Environment Agency of
England and Wales (Gross-Sorokin et al., 2006) and
by the European Commission through its proposal
for EE2 to become a priority substance requiring
control (EC, 2012).
But this is a story that is far from over, and is one
that continues to raise important questions that will
apply not only to EE2 but to any other pollutants
exerting damaging but often sub-lethal effects at
very low concentrations. For a decision to regulate
EE2 has not been agreed. A critical question
is whether we as a society are willing to pay a
potentially very high premium to be precautionary
and exclude EE2 from the environment.
Alternatively, would we, as a society, prefer to live
with the impacts of EE2 and other oestrogens on
wildlife; are they acceptable risks? To what extent
is society, which ultimately bears the benefits of
flexible fertility but also the costs of cleaning up
its unintended consequences on the environment,
having a say on this decision?
This historical retrospective allows us to identify
several important lessons, which are central
not only to regulation of EE2 and other steroid
oestrogens but also for many other low-level
chemical pollutants in the environment with
sublethal effects, alone or in combination, now and
in the future.
13.7.1 Lesson 1: for low-level pollutants in
the environment, is the price of being
precautionary simply too high?
With regulation of EE2 now a serious proposal
in Europe, the water industry, regulators and
national governments are faced (as will be the case
with many other low-level pollutants) with risk
management that will be a costly process if EE2 is
to be removed from sewage treatment works final
effluents to the vanishingly low levels that will be
required for compliance. The target level proposed
by the EC for EE2 as an annual EQS has been set at
0.035 ng/L for inland surface waters (e.g. rivers and
lakes). This is the regulatory concentration in the
water body itself, not in the final effluent discharged
from the sewage treatment works. However, as the
UK Demonstration Programme has shown, reducing
levels of EE2 in final effluents via end‑of‑pipe
treatment to enable compliance with this EQS
(e.g. for those water bodies with low dilution
receiving large volumes of oestrogenic effluent)
will be extremely difficult, The most promising
technology, granular activated carbon, might achieve
this, but it is expensive and may have a potentially
large carbon footprint. Mild ozonation may also be
(9) Draft report on the proposal for a directive of the European Parliament and of the Council amending Directives 2000/60/EC and
2008/105/EC as regards priority substances in the field of water policy (17.07.2012). Proposer Richard Seeber, European Member
of Parliament.
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Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
effective, but this will still be expensive in terms of
capital set up costs (10).
Measuring compliance with the low EQS for EE2 and
E2 will also be a significant challenge. The techniques
available to measure such very low levels of EE2 in
natural waters and effluents are hardly routine. Some
efforts have been made to develop more amenable
enzyme-linked immunoassay analysis methods but
these have been fraught with issues around selectivity
and sensitivity at the very low levels of detection
required. This leaves both the water industry and
regulators with a fundamental problem: it will be
costly to remove EE2 to enable compliance with the
target EQS, and costly to monitor and demonstrate
legal compliance itself. So while it is technically
possible to develop an EQS, in practice it may be
very hard to implement. The widespread nature of
contamination has only added to the problem: this
is unlikely to be an issue in one isolated location, but
one with significant cost implications across Europe
and beyond.
What other options might there be? Since EE2 is
both the most potent of the steroid oestrogens
and, seemingly, the most difficult to remove by
conventional sewage treatment, could there be an
argument for substituting this as the active ingredient
in the contraceptive pill, leaving the remaining
oestrogens to be removed conventionally at less cost?
But what would replace it? If there were sufficient
demand or need, the pharmaceutical industry could
continue to provide women with access to birth
control and reproductive choice while substantively
altering the design of pharmaceuticals to protect the
environment from unnecessary harm. This would
represent a constructive precautionary approach (11).
Is this option preferable?
13.7.2 Lesson 2: low-level pollutants with sublethal
effects present fundamental issues for the
precautionary principle
A number of definitions and interpretations of
the precautionary principle exist (see Weiner
and Rogers, 2002; Gee, 2006), of which the Rio
Declaration (UN, 1992) is one that is widely cited:
'Where there are threats of serious or
irreversible damage, lack of full scientific
certainty shall not be used as a reason for
postponing cost-effective measures to prevent
environmental degradation' (12).
The chapter on the precautionary principle (PP) in
this volume, provides different definitions of the
PP taken from other international treaties and the
European Court of Justice, including the working
definition proposed by the EEA which is designed to
improve common understanding about the meaning
and application of the PP.
However, for this chapter it will be useful to consider
the constituent parts of the Rio definition, the first
of which deals with threats of serious or irreversible
damage.
It is not in dispute that intersex in fish represents
both serious and irreversible damage to fish and
that exposure to environmentally relevant levels
of EE2 has adverse effects on fish reproduction,
an ecologically relevant measure of impact.
Uncertainties remain, particularly around fish
population level effects, but the precautionary
principle aims to promote action in the face of such
uncertainties, when there is evidence of serious
environmental damage that is irreversible. In fact,
the level of scientific certainty concerning the
risks (or threats) posed by oestrogens as mixtures
to aquatic life, mediated through their endocrine
disrupting effects is extremely high and there
seems to be little or no doubt that there is sufficient
evidence to justify applying the precautionary
principle (Gross-Sorokin et al., 2006). Responding
to this evidence of harm, the water and chemical
industries (and indeed some scientists) have
increasingly asked the question, 'so what?' There
may be male fish with eggs in their testes and this
might be unpleasant, irreversible and widespread.
But does it seriously damage fish populations?
(Webb et al., 2003). Why pay potentially vast sums
(10) It should be noted that some European countries have decided to clean up wastewater, even in the absence of regulation of EE2
and E2, but in recognition of contamination of wastewater by pharmaceuticals, pesticides and endocrine disruptors. Full-scale
treatments will be installed on more than 100 Swiss WWTP treating about 80 % of the Swiss municipal wastewater. The first
full-scale ozonation plant will go in operation in Spring 2013 and will cost only 5 EUR/person/year including both capital and
operational costs, because sand filtration already exists on this plant.
11
( ) There has been some research towards development of contraceptive formulations such as the progesterone-only pill, which do not
contain oestrogen and instead target the female reproductive cycle more specifically (Lakha et al., 2007).
(12) European Commission Communication on the Precautionary Principle (EC, 2000) sets out guidance on when to apply the
A
precautionary principle e.g. 'where there are reasonable grounds for concern'. The Communication sets out a set of general
principles underpinning application of the PP This includes 'examining costs and benefits' which 'entails comparing the overall
cost to the Community of action and lack of action, in both the short and long term. This is not simply an economic cost-benefit
analysis: its scope is much broader, and includes non-economic considerations, such as the efficacy of possible options and their
acceptability to the public' (p. 4). It also includes the need for the decision-making process to be 'transparent'.
Late lessons from early warnings: science, precaution, innovation
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of money for risk management when the seriousness
of such population — level effects is uncertain?
These populations might collapse in the future, as
indicated in the Great Lakes study of EE2 (Kidd
et al., 2007), but maybe they will not. Is intersex an
unpalatable but acceptable harm?
But even if the seriousness of the harmful threats
is accepted, the precautionary principle's Achilles
heel, however, as defined in the Rio Declaration,
lies in the words 'cost effective'. The central issue
for oestrogens (and quite possibly for many other
chemicals that cause sublethal impacts at very low
levels) is that any risk management measures are
likely to be very costly, and as we have discussed
above, this may be a price too high to pay.
13.7.3 Lesson 3: the need for an open debate on
precaution and decision-making
Our environment is full of low-level pollutants
present as mixtures that cause sublethal effects.
The European Inventory of Existing Commercial
Chemical Substances (EINECS) lists over
100 000 chemical compounds and little is known
about the toxicity of about 75 % of them. Several
hundred new substances are marketed each year after
some basic premarket toxicity testing and these are
registered in the European List of Notified Chemical
Substances (ELINCS), which currently contains about
2 000 chemicals.
The potentially high costs of risk management
have combined with protracted debates about
what constitutes acceptable harm to seriously
delay decision-making about the regulation of
EE2 and other steroid oestrogens. This has been
compounded by a precautionary principle whose
definition includes issues of disproportionate
cost and cost effectiveness, either explicitly or
implicitly (13). Defined in this way the precautionary
principle may be logical and rational, but it can also
paradoxically become a perfect excuse for inaction
or, at best, seriously delayed action. It is therefore
perhaps no surprise that eight years after the
UK government officially recognised EE2 and other
steroid oestrogens as posing a risk to wildlife that
should be managed, and some 30 years after the first
observations of their effects in wild fish populations,
that the regulation of EE2 is still undecided. And
even if the EC proposal is agreed, it will not come
into force until at least 2015.
In 2007 the new chemicals EU regulation, REACH
(Registration, Evaluation, Authorisation and
restriction of CHemicals) was enacted. This
reformed chemicals laws and set up procedures and
responsibilities to address the backlog of untested
chemicals, focusing on some 30 000 substances
now being evaluated by industry and the new
EU chemicals agency ECHA. Hazard identification
and quantification is challenging however, and
implementing monitoring programmes and
conducting risk assessments for this whole 'chemicals
universe' is unfeasible. Moreover, we do not have
the tools to fully analyse how mixtures of these
chemicals behave. The only logical way forward
seems to be to reduce exposure as much as possible
— to be precautionary. But this comes at a price
and raises ethical questions of where responsibility
should lie. Do we want the water industry to reduce
exposure through costly treatment? Do we want the
pharmaceutical industries to invest in developing
new, less harmful contraceptive pills? Either way, are
we as a society, prepared to pay for it? Do we care?
Such long delays have, one might argue, been
completely within the spirit of the precautionary
principle at least as defined in the Rio declaration.
The precautionary principle is well intended and
should expedite decision-making in the face of
uncertainty. But in reality decision-making has been
painfully slow. We are left with the uncomfortable
knowledge of a serious environmental issue that has
been, and continues to be, unresolved: one which
we may have to live with if the price of precaution is
deemed too high. This is a bitter pill to swallow.
The average fish in a stream or person in the street
now has hundreds of novel compounds in their
bodies that were not there 60 years ago. We can
measure them in adult and foetal tissue. We know
they have detrimental effects such as intersex in fish.
We have changed the chemical environment of the
developing organism. EE2 is a perfect case study
of how we are responding as a society to difficult
decisions regarding the need for, and challenges of,
risk management for these low-level pollutants with
chronic sublethal effects.
(13) The EU communication on the precautionary principle also recommends an 'Examination of the benefits and costs of action and lack
of action'. This 'examination of the pros and cons should include an economic cost benefit analysis where this is appropriate and
possible.However, such an 'examination of the pros and cons cannot be reduced to an economic cost-benefit analysis'. It is wider in
scope and includes non-economic considerations (EC, 2000). The EEA working definition of the PP also uses the broader 'pros and
cons' rather than 'costs and benefits' for similar reasons, including the importance of the non-quantifiable 'cons' such as the melt
down of public trust in scientists and policticians which occurred in the BSE saga (see EEA, 2001, Ch. 15 on BSE).
296
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A key observation from this case study is that the
public has been and continues to be silent witnesses.
A key lesson learnt from previous case studies
(EEA, 2001; Gee, 2006; Lokke, 2006) has been that
the process of applying precaution must encourage
public participation, such that the costs of action
(e.g. risk management) and potential costs of inaction
are debated. This enables value judgements and
decisions to be made in an open and democratic
way. Transparency of decision‑making and the need
to involve all interested parties as early as possible
is a central tenet of the European Commission
communication on the precautionary principle
(EC, 2000), which states that:
'All interested parties should be involved
to the fullest extent possible in the study of
various risk management options that may
be envisaged once the results of the scientific
evaluation and/or risk assessment are available.'
The US National Academy of Sciences has also
repeatedly stressed the importance and need
for stakeholder involvement at all stages of the
risk‑based decision-making process (NAS, 2009.)
Prior to this, in 1998 the UK Royal Commission
on Environmental Pollution published a report on
Setting Environmental Standards (RCEP, 1998) in
which it emphasised that decisions must be informed
by an early understanding of peoples values, with
a process that ensures transparency and openness.
This is a view that is shared by the chemicals industry
(Webb et al., 2003).
The Royal Commission also identified specific
mechanisms by which this could be achieved. It
stated that those affected have a right to make
their views known before a decision is made and
that 'it is no longer acceptable for decisions to be
negotiated privately between the regulator and
polluter' (RCEP, 1998). This was fully endorsed
by the UK government in their response to the
Commission's report. But this endorsement is yet to
translate into action. Opportunities for engagement
and consultation that do exist are insufficient (14).
Decisions regarding regulation of EE2 and its sister
oestrogens, and the dilemmas and issues these
pose, have been, and continue to be undertaken
in a poorly understood, closed process that has
little engaged the public. It is vitally important
that decision-makers understand about the
acceptability of risk, appetite for precaution and
the willingness to pay for being precautionary.
The views and concerns of the public have to
date however gone largely undocumented. This
is not an academic exercise: it is fundamental
to making a decision on such a complex and
potentially costly issue, a point emphasised by
the Royal Commission in 1998 and the European
Commission in 2000. Without public support the
costs of risk management, of regulation of EE2,
may be seen by policy makers as disproportionate.
It might be that the weight of evidence suggests
that public opinion is not on the side of risk
management, that we are prepared to live with
endocrine disruption in the environment as
collateral damage associated with flexible fertility
in our own species. But what is very clear is that
without asking the public it will be far easier to
come to a conclusion based largely on costs alone.
This loads the dice before they are thrown.
(14) For example in the development of the next round of River Basin Management Plans across the EU under the Water Framework
Directive.
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Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
Table 13.1 Early warnings and actions
1938
EE2 marketed as a contraceptive
1962–1969
USFDA approve the birth control pill and the United Kingdom allows it to be prescribed through its National Health
Service
1970
Pill users increase in number from 50 000 to 1 million
1976
First speculation that oral contraceptives might pass through sewage treatment works (STWs) into the aquatic
environment
1979
Kinloch Nelson and Bunge publish a study showing low sperm counts in 93 % of men about to undergo vasectomies
1982
Routine health checks of male fish (roach) in a UK river show the presence of oocytes in testes (intersex). The rate
of hermaphroditism is very high in comparison to the norm
Mid-1980s
First reports of contraceptive pill hormones in river water
1985
High levels of female-specific yolk protein (vitellogenin) found in blood of male fish in a fish farm receiving effluent
containing river water
1985
Nonylphenols discovered in sewage effluents and in sludge
1991
National survey shows that oestrogenic effluents are widespread in England and Wales
1991
4-Nonylphenol is rediscovered as an oestrogen
1992
Meta-analysis of 61 studies shows sperm counts have declined 50 % in the preceding 50 years
1993
Theo Colborn and Clement publish 'The Wildlife Human Connection' suggesting widespread endocrine disrupting
effects in wildlife and humans as a result of exposure to chemicals
1994–1996
Sharpe and Skakkebaek publish a hypothesis that testicular cancer, hypospadias, cryptorchidism and lowered semen
quality are part of a syndrome caused by exposure to environmental oestrogens during foetal life
1993
BBC Horizon screens the award-winning documentary 'Assault on the male'
1995–1996
Surveys show that intersex is widespread in roach and is especially prevalent downstream of STWs with low effluent
dilution. Feminising syndromes in other wildlife species are reported
1996
Major European workshop on endocrine disruptors are held, jointly sponsored by the European Commission, the
European Environment Agency, the European Centre for Environment and Health and the World Health Organization
1998
Steroid oestrogens, and EE2 in particular, are shown to be the most potent oestrogenically active substances in
domestic effluent
1998
Royal Commission on Environmental Pollution publishes a report Setting environmental standards, in which it
emphasises that decisions must be informed by an early understanding of people's values. It is endorsed by the
United Kingdom government
1999
European Union launches a Strategy on endocrine disrupters
2001
Feminisation is shown to be a permanent phenomenon that is progressive with age i.e. duration of exposure
2001
Schering publish a whole life-cycle study showing EE2 causing full sex reversal of males to females at concentrations
> 2 ng/L
2002
Silva et al. show additive effects of oestrogenic endocrine disrupting chemicals in vitro: 'something from nothing'
2002-2003
More widespread surveys show intersex fish are present throughout the United Kingdom. Widespread antiandrogenic activity is discovered in sewage effluents
2003
Nonylphenol and nonyphenol ethoxylates are banned in the European Union as a hazard to human and
environmental safety. Serious evaluations of other endocrine disruptors such as BPA take place
2004
Predicted No Effect Concentration (PNEC) of 0.1 ng/L derived for EE2
2004
UK Endocrine Disruption Demonstration Programme commences, evaluating the efficiency of removing oestrogens
from sewage treatment processes
2007
Draft environmental quality standard for EE2 prepared by the Environment Agency of England and Wales
2008
Experimental lakes study in Canada reports a population crash of fish after exposure to EE2 at 6 ng/L
2009
UK Demonstration Programme reports first phase results showing difficulty removing EE2 to the PNEC using
conventional sewage treatment approaches
2012
298
17α-ethinyl estradiol (EE2) synthesised
1943
European Commission publishes proposals to regulate EE2 as a 'Priority Substance' under the EU Water Framework
Directive, which if accepted may come into force after 2015. An amendment to this proposal is tabled in July 2012
which proposes delay of setting EQS until 2016, with the aim of meeting this by 2027'
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Emerging lessons from ecosystems | Ethinyl oestradiol in the aquatic environment
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